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NURS 122 Lecture WEEK ONE Questions and Correct Answers the Latest Update and Recommended Version
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NURS 122 Lecture WEEK ONE Questions and Correct Answers the Latest Update and Recommended Version
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TestTrackers: Unlock Your Exam Potential! | Quality Practice Materials | Boost Your Confidence Today!NURS 122 Lecture WEEK ONE Questions
and Correct Answers the Latest Update
and Recommended Version
discussion
✓ an informal oral consideration of a subject by two or more healthcare personnel to
identify a problem or establish strategies
report
✓ oral, written, or computer-based communication intended to convey information to others
The process of making an entry on a patient record is called
✓ recording, charting, or documenting
clinical record
✓ a formal, legal document that provides evidence of a patient's care
"The nurse has a duty to maintain confidentiality of all patient information" is said by who?
✓ The American Nurses Association (ANA) Code of Ethics
PHI is the abbreviation for
✓ Protected Health Information
purposes of patient records include
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✓ communication, planning patient care, auditing health agencies, research, education,
reimbursement, legal documentation, healthcare analysis
the traditional patient record is called
✓ a source-oriented record
narrative charting consists of what?
✓ Written notes which include routine care, normal findings, and patient problems
examples of diagnostic reports are
✓ laboratory reports, x-ray reports, CT scan reports
examples of consultation reports are
✓ physical therapy and respiratory therapy
the abbreviation for POMR is
✓ problem-oriented medical record
what is a POMR?
✓ data is arranged according to the problems the patient has rather than according to the
source of the information
what are some advantages and disadvantages of a POMR?
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✓ advantages: they encourage collaboration, and that the problem list in the front of the
chart alerts caregivers to the patient's needs, making it easier to track the status of each
problem
✓
✓ disadvantages: not all caregivers can use the charting format effectively, constant
vigilance is required to maintain an up-to-date problem list which can be inefficient
what is a database?
✓ all information known about the patient
SOAP is an acronym for
✓ subjective, objective, assessment, and planning
subjective data
✓ what the person says about himself or herself during history taking
objective data
✓ information that is seen, heard, felt, or smelled by an observer; signs
assessment
✓ interpretation or conclusions drawn about the subjective and objective data
interventions
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